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Event Notification Report for January 3, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/30/2010 - 01/03/2011

** EVENT NUMBERS **


46512 46517

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Agreement State Event Number: 46512
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: BANNER GOOD SAMARITAN MEDICAL CENTER
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ 07-478
Agreement: Y
Docket:
NRC Notified By: AUBREY V. GOODWIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 12/27/2010
Notification Time: 11:13 [ET]
Event Date: 12/22/2010
Event Time: 12:30 [MST]
Last Update Date: 12/27/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING AN HDR MISADMINISTRATION

The following report was received from the State of Arizona via fax:

"At approximately 12:30 PM December 22, 2010, the Licensee phoned the Agency [Arizona Radiation Regulatory Agency] to report an HDR [High Dose Radiation] misadministration. A breast cancer patient was undergoing treatment with a Nucletron MicroSelectron-HDR. A Savi-8 Accelerated Partial Breast Irradiation Device was connected to the HDR. This is manufactured by Cianno. The source apparently punched through the catheter and moved along the skin surface during the treatment. The patient did not notice the source was outside the tube. The source retracted normally to the shielded position. The physicist estimates that the patient's skin received 5 Gray if the source moved along the skins surface but if the source stuck in one position the patient's skin received 50 Gray. According to the licensee the catheter is easily kinked which can cause this failure. This has happened before but is the first time that this has resulted in an exposure. In the past, the licensee would repair the catheter with heat shrink tubing.

"The Agency continues to investigate the actions of the licensee.

"The U.S. NRC and the Arizona Governor's office have been notified of this event.

"Press coverage is not anticipated."

Arizona First Notice: 10-016

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Non-Agreement State Event Number: 46517
Rep Org: MT OPERATING OF NJ, LLC
Licensee: MT OPERATING OF NJ, LLC
Region: 1
City: HOPELAWN State: NJ
County:
License #: 29-30465-01
Agreement: Y
Docket:
NRC Notified By: FRANK PENNISI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/30/2010
Notification Time: 09:19 [ET]
Event Date: 12/29/2010
Event Time: 21:30 [EST]
Last Update Date: 12/30/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
SAM HANSELL (R1DO)
ANGELA MCINTOSH (FSME)
DARYL JOHNSON (ILTA)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

STOLEN TROXLER MOISTER DENSITY GAUGE

A company employee was robbed, at gunpoint, of his car which contained a Troxler moisture density gauge in the trunk. The employee works for MT Operating of NJ, LLC, and was unable to return the gauge to the normal company storage area in Wallingford, CT., at the end of the day. The employee began working a second job in Bloomfield, CT, where the robbery took place. The employee was also robbed of his cell phone and wallet, in addition to his car containing the gauge.

The nuclear gauge is a Troxler Model 3411B, S/N 4783, which contains two radioactive sources. One source is 40 mCi of Am-241/Be and the other source is 8 mCi of Cs-137.

The licensee has notified the Bloomfield Connecticut Police Department to investigate the theft (case # 10-26288).

The licensee has other company employees searching the area in an attempt to locate the missing vehicle.

The licensee plans to make a press release and offer a cash reward.

* * * UPDATE ON 12/30/10 AT 2200 EST FROM PENNISI TO HUFFMAN * * *

The licensee states the Bloomfield Police Department has recovered the Troxler gauge. The circumstances of the recovery are not yet known, however, the gauge appears to be undamaged. Officials from the State of Connecticut have surveyed the gauge and determined found no evidence of unusual radiation levels. The gauge is in Police custody.

R1DO (Hansell), FSME (Watson) and ILTAB (Johnson via email) notified.

* * * UPDATE ON 12/30/10 AT 2300 EST FROM PENNISI TO SNYDER * * *

State of Connecticut informed the NRC Operations Center that the Troxler has been turned over to the licensee's RSO.

R1DO (Hansell), FSME (Watson) and ILTAB (Johnson via email) notified.


THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Thursday, March 29, 2012